Medical History Form - Oregon Medical Group
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Medical History Form
Date _____________ Patient Name _______________________________ Age ______ Date of Birth ______________
Other Physicians involved in my care ___________________________________________________________________
Referred to this office by _____________________________________________________________________________
What areas or issues would you like to discuss today: (Please limit to 3 items)
1. ___________________________________________
2. ______________________________________________________
3. _____________________________________________________________________________________________________
PREVENTATIVE HEALTH STATUS:
Date of last physical exam: ________________ Last eye exam: ________________ Last dental exam: ________________
Have you ever had a colonoscopy or sigmoidoscopy?
yes
no When/Findings: _____________________________
Have you ever had a bone density test?
yes
no When/Findings: _______________________________________
Do you have an Advance Directive for health care decisions?
yes
no
Last immunizations: (please give date of most recent vaccination or series completion date)
Tetanus: ___________ Hepatitis B: ___________ Hepatitis A: ___________ HPV: ___________ Influenza: ___________
Pneumonia: ___________ Shingles: ___________ TB skin test result: _________________________ Date: ___________
FOR WOMEN ONLY:
Date of last period: ___________ Last Pap: ___________ Age periods began: ______ Age at start of menopause: ______
Have you had a mammogram?
yes
no Most recent date ___________ Result _____________________________
Birth control method: ________________________________________________________________________________
Have you had any pregnancies?
yes
no
Total number ____________Miscarriages/Abortions ________________
Problems during pregnancies: __________________________________________________________________________
FOR MEN ONLY:
Have you had a PSA blood test and/or prostate exam?
yes
no
Last Date __________ Result__________________
SOCIAL HISTORY:
Occupation: _______________________________ Former Regions of Residence: _______________________________
Marital Status:
Single
Married
Domestic Partnership
Divorced
Widowed
Living Situation:
Alone
Roommate
Spouse
Parents
Significant Other
With Children
Have you been in a relationship where you were hurt, threatened or made to feel afraid?
yes
no
Do you drink alcohol?
yes
no
How many per week? __________________ Quit/When ________________
Do you use tobacco?
yes
no
How much/how long? __________________ Quit/When ________________
Do you drink caffeine?
yes
no
How much per day? _____________________________________________
Have you used drugs?
yes
no
Which ones? _________________________ Quit/When ________________
Do you exercise?
yes
no
Type: _______________________
How often? _____________________
Do you follow a diet?
yes
no
Please describe: ________________________________________________
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4032-00 12/09
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